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WELL PERMIT APPLICATION FORM UNIT Iv S D� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED Ircetion k made N compliance with <br /> Appikadon is hereby made to San Joaquin County tat a permit tt construct andJ r install tiu work descried. This app' <br /> Chapter 5-1775.3 and the Standards of San Joaquin County Public Health Services.Envi tinmem Health Division. <br /> San Joaquin County Development Tale, P ^ r t •� L q5>!c7 Parcels Assessois Y?-070^/0 <br /> SGit{'fi 1 Cross Street City p <br /> wELL local on 2 3 4r5Q $: <br /> S¢. l�.12.r�n Address 23 5 ,jcn C ity 3i7 -Phone#_A <br /> ' YY•ZY3 PAIpi5 <br /> PROPERTY Owner-,TOT` <br /> - t - <br /> - it. 1- Address3233 F'iz5ac4AsNk(5 Gitye+�r1v�L^' -Zip 957HL Lidt Y7 T Phone#5/G 63B-7z7G <br /> 0-67 Contractor'•!-*r,•' -^ P) <br /> tvz- Phone# <br /> k <br /> Consultant I Sub Contractor Addressw �k /a fGWdgLl•p4eo_ <br /> }� Range Section 2 4( <br /> Township 33 — <br /> GIS Coordinates:X,� 'Y�-- <br /> WORK TO BE PERFORMED a below) <br /> p <br /> MEW WELLI BORING(CPT.G�BE,HYOROPUNCN.HAND-AUGER.OTHERDESTRUCTION(choose typ <br /> ') p OVERBORE <br /> !SOIL BORING# 0 PRESSURE GROAT <br /> )gWELL# <br /> •Other. <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL r MULTIPLE CASINGS?p YES kNOb wELL CASING DIA:,-r— <br /> `MONITORING `'► ,$Q'10LLOW STEM ^'� OTA•OF BOREHOLE CASING `t� TYPE OF CASING: U STEEL gPVC 6 OTHER: <br /> 0 EXTRACTION U AIR i-AMfAERIORIVEN DEPTH OF GROUT SEAL AJt LI r TREMIE TYPE TO BE USED: ',$AUGERS *OSE <br /> p VAPOR p MUD ROTARY <br /> GROUT SEAL PUMPED:�Yes 0 No !NOTE: MAXIMUM FREE-FALL DEPTH IS 30 <br /> p AIR SPARGE PUSH POINT q0OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> I <br /> SOIL BORING U RAND AUGER APPROX.BORING DEPTH O l ES,list specifications here): <br /> 0 OTHER: U OTHER CONDUCTOR CASING PROPOSED_ _ <br /> NOTE: OFFSITE BORINGS RE IRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certiry that l have prepared this application and that the work will ba done In accordance with San Joaquin County t"'the P"State 'ce Of the Rules <br /> and hereby <br /> Malty a the SaM1 Joaquin County. Homeowner or the word aganCs signature cer%Ii'm the following:"1 cudfy chat in the puformance Of the work <br /> for which this permit Is issued,1 s#rill not employ persons subject to WORKERS'COMPENSATION taws of Catitomla." Contractor'srsoru Subjecttto rfing or sub <br /> - <br /> of <br /> signature terrifies the following:'I certify that In the performance of the work for which this permit;s issued,!shall employ pe <br /> WORKERS'COMPENSATION Laws Of Catdornie' -•'tr;;H.R$`IN ADI2AI.(ICE). 0 „ 'u%1'DEQ,I'1•IRED`'II�S`,PtE'�CJ. 10 5'+ <br /> n�rCCa]kSPCTOR48i1NAI <br /> ! SY-(017- 3.vrAcrv�A�---mow\ 7.hc P `tia>• �NlAwt�. <br /> �j_ TiUelCompany <br /> Signed x <br /> n Data -7-10-r7U <br /> Print Name�J Fiuctn.�erlovi,e I _ <br /> DEPARTMENT USE ONLY -Il 4-oo Are. <br /> Date Issued ( <br /> Apolicatian Accepted By Date Final Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> UONLY: AID#FEE INFO AMOUNT REMIT EDCHECK A RECD BY DTEPERMIT/ODE�OtIT It INVOICE 1/18/2000 <br />